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An Extremely Effective and Safe Approach of Guiding Catheter Crossing over Spasmodic Radial or (and) Brachial Artery in Patients Whose Percutaneous Coronary Intervention Was Undergone via Radial Artery Access

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ISSN Online: 2164-5337 ISSN Print: 2164-5329

DOI: 10.4236/wjcd.2018.82017 Feb. 24, 2018 169 World Journal of Cardiovascular Diseases

An Extremely Effective and Safe Approach of

Guiding Catheter Crossing over Spasmodic

Radial or (and) Brachial Artery in Patients

Whose Percutaneous Coronary Intervention

Was Undergone via Radial Artery Access

Zhuhua Ni

1*

, Lefeng Wang

1

, Xinchun Yang

1

, Junping Deng

2

, Jianhong Zhao

3

, Jiqiang Zhang

4

,

Shuying Qi

5

, Tao Zhang

6

, Yong Li

7

1Heart Center, Beijing Chaoyang Hospital, Institute of Cardiovascular Disease, Capital Medical University, Beijing, China 2Linfen People’s Hospital, Shanxi, China

3Jincheng Heart and Brain Disease Hospital, Shanxi, China 4Linfen Second People’s Hospital, Shanxi, China

5Yantai Haigang Hospital, Shangdong, China 6Ningjun People’s Hospital, Shandong, China 7Leling People’s Hospital, Shandong, China

Abstract

Objective: Percutaneous coronary intervention (PCI) via the radial artery access has more advantages than that of femoral artery access, while radial or (and) brachial artery have tendency to be spasmodic. We sought to investigate the effectiveness and safety of guiding catheter crossing over spasmodic radial or (and) brachial artery segments by the aid of PCI wire and balloon com-pared with traditional anti-spasmodic approach. Methods: The clinical data of 168 patients with coronary artery disease (CAD) (group A), whose PCI was performed via radial artery access with radial or (and) brachial artery spasm or (and) dissection and guiding catheter passing through spasmodic segments successfully by the aid of PCI guiding wire and balloon were analyzed retros-pectively, simultaneously, the other 73 patients (group B) who used conven-tional approach to cross over the spasmodic radial or (and) brachial artery segments were treated as the control. The success rate, the time consumption and the complication were compared between the two groups. Findings: There was no significant difference in the spasmodic site between the two groups (all p value > 0.05). The success rate in group A was significantly How to cite this paper: Ni, Z.H., Wang,

L.F., Yang, X.C., Deng, J.P., Zhao, J.H., Zhang, J.Q., Qi, S.Y., Zhang, T. and Li, Y. (2018) An Extremely Effective and Safe Approach of Guiding Catheter Crossing over Spasmodic Radial or (and) Brachial Artery in Patients Whose Percutaneous Coronary Intervention Was Undergone via Radial Artery Access. World Journal of Cardiovascular Diseases, 8, 169-182. https://doi.org/10.4236/wjcd.2018.82017

Received: January 29, 2018 Accepted: February 21, 2018 Published: February 24, 2018

Copyright © 2018 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

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DOI: 10.4236/wjcd.2018.82017 170 World Journal of Cardiovascular Diseases higher than that in group B (168(100%) vs 28 (38.4%), p < 0.0001). As for those of successful crossover in the two groups, the time consumption of guiding catheter crossing over spasmodic segment in group A was shorter than that in group B (p < 0.0001). The incidence of forearm hematoma in group A was lower than that in group B (7(4.2%) vs 14 (19.2%), p < 0.0001). Conclusions: It is more effective and safer for guiding catheter crossing over spasmodic or (and) dissected radial or (and) brachial artery segments by the aid of PCI guiding wire and balloon than using the routine approach of ad-ministration of anti-spasm drugs for trans-radial PCI.

Keywords

Trans-Radial PCI, Radial or (and) Brachial Artery Spasm, Guiding Catheter Crossover of Spasmodic Segment, Guiding Wire and Balloon Assistance

1. Introduction

There are many advantages when percutaneous coronary intervention (PCI) is undergone via radial artery (RA) access compared to femoral artery access for patients with coronary artery disease (CAD). Less vessel puncture-related com-plications, less pain and more willingness of the patients and shorter hospitaliza-tion time for PCI via radial artery access make it the most often adopted vessel access in current clinical practice for PCI [1]. Comparing with femoral artery, radial artery or (and) brachial artery (BA) have tendency to be spasmodic. The success rate of the traditional anti-spasmodic method, i.e., anti-spasmodic drugs, such as nitroglycerine, nitroprusside, diltiazem, etc., to relieve radial or (and) brachial artery spasm is relatively low. Once spasm cannot be relieved, the guid-ing catheter is hard to cross over the spasmodic artery, and even severe dissec-tion or hematoma occurs in the upper limb [1]. Under the circumstances, fe-moral artery, contralateral radial or ulnar artery has to be punctured. It will cer-tainly aggravate the pain, prolong procedural and hospitalization time, and im-pose economic burden of the patients (especially femoral artery is punctured and vessel suture instrument is used) [2]. To date, it has been demonstrated in our experience that the problem can be solved by the aid of PCI guiding wire and balloon effectively and safely. It is our strong recommendation to apply this approach to cross over spasmodic radial artery or (and) brachial artery when PCI is undergone via radial artery access.

2. Subjects and Methods

2.1. Study Subjects

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DOI: 10.4236/wjcd.2018.82017 171 World Journal of Cardiovascular Diseases cases in group A were applied PCI wire and balloon-guided spasmodic segment crossover, and 73 cases in group B were applied routine methods of administra-tion of anti-spasm drugs to cross over the spasmodic segment) were analysed and compared retrospectively so as to observe the success rate and complications between the two groups and to identify the advantages and disadvantages of the two methods. The inclusion criteria: 1) patients whose coronary angiography was performed via the radial artery access and the coronary lesions were suitable for PCI; 2) PCI guiding catheter could not cross radial or brachial artery and radial artery angiography confirmed that radial or (and) brachial artery spasm occurred. Exclusion criteria: 1) severe brandy cardia (heart rate < 50/min); 2) hypotension (blood pressure < 90/60 mmHg) or cardiogenic shock; 3) anatomi-cal abnormality of radial or brachial artery, e.g. radial or brachial artery loop ex-isted.

Generally, a 6F guiding catheter was chosen for trans-radial artery PCI; how-ever, as for some complex cases, such as bifurcation lesions, a 7F guiding cathe-ters can also be selected according to the situation, while a 7F guiding catheter was not routinely applied in patients of thin body size.

2.2. Identification of Radial or (and) Brachial Artery Spasm via

the Radial Arterial Access

1) Operators felt resistance when manipulating interventional instruments (such as the guiding wire, angiographical catheter, or guiding catheter), or can-not push forward the interventional instruments; 2) Patients may feel swelling pain in the forearm; 3) The injection of contrast medium through the arterial sheath or the catheter revealed focal or diffuse contraction of radial artery or (and) brachial artery, i.e. the vessel became narrower in diameter and contrast medium exosmosis was often seen.

2.3. Key Operation Points of PCI Wire and Balloon-Guided

Spasmodic Segment Crossover

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DOI: 10.4236/wjcd.2018.82017 172 World Journal of Cardiovascular Diseases USA; Sequent, Braun, USA, etc ) should be selected for the matching. Sometimes a 7F guiding catheter may be selected for complex PCI, then a balloon of 2.5 mm in diameter should be selected for the matching. The balloon length should not be too short, and the best length is about 15 mm or 20 mm. 4) Under the X-ray guidance, the balloon selected was deliver to the catheter tip through the guiding wire (0.014" in diameter), during which the key point was to push only 1/2 of the balloon outside the guiding catheter while the rest half was kept inside the ca-theter. 5) After the balloon was expanded with 6 - 8 atm (1 atm = 101.325 kPa), the operator must push the guiding catheter (rather than the outer rod of the balloon catheter, we called it as balloon- guiding catheter complex (BGCC)) slowly, then the BGCC will go forward simultaneously to pass through the spasmodic segment eventually, at which time no obvious or slight resistance could be felt; after passing through the spasmodic segment, the resistance will be further reduced. If the resistance during the pushing process was large, no force should be applied for the crossover. Once it was confirmed that the catheter had crossed over the spasmodic segment according to the hand feeling, the operator should stop pushing the guiding catheter, and then deflate the balloon. When confirmed the complete deflation by X-ray, the balloon should be retracted to the guiding catheter, followed by re-angiography via the guiding catheter. If the catheter confirmatively passed through the spasmodic segment, the balloon should be withdrawn; the PCI wire can be withdrawn at the same time or still remained in the catheter. 6) The “Loach” slippery guiding wire (preferred) or the “Green” guiding wire was then used to complete the placement of the guiding catheter. 7) After completing PCI, the “Loach” guiding wire was then re-inserted so as to assist the careful withdrawal of the guiding catheter back to the distal end of the spasmodic segment and re-angiography was needed. If angiography revealed no contrast medium extravasation in the spasmodic segment, the guid-ing catheter and sheath can be directly removed; if contrast medium extravasa-tion was found, elastic bandage should be applied at the site of contrast medium extravasation (Figures 1-3).

2.4. Routine Crossover Method

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DOI: 10.4236/wjcd.2018.82017 173 World Journal of Cardiovascular Diseases

(a) (b)

(c) (d)

Figure 1. Male, 43 years old, radial artery spasm together with severe dissection. (a): Radial artery spasm together with severe dissection (arrow). (b): A BMW guiding wire successfully passed through the spasmodic dissection segment, the half of the balloon (2.0 mm × 15 mm) was positioned in the guiding catheter and the rest was kept in the blood vessel and was dilated with 8 atm (single arrow); significant exudation of the contrast medium could be observed locally (Double arrow). (c): When maintaining the filling sta-tus of the balloon, the guiding catheter was pushed in vitro (rather than the outer rod of the balloon), then the guiding catheter and balloon, as a whole (namely the balloon- guiding catheter complex, BGCA), successfully passed through the dissected segment (single arrow); the exudation of the contrast medium can be observed locally (double ar-row). (d): After PCI, the original spasmodic segment was significantly relieved, the dis-sected segment was closed, and no contrast medium exudate could be observed (arrow).

3) If spasm was found relieved or reduced by angiography, the “Loach” wire should be used to assist the crossover of guiding catheter. If any obvious resis-tance was encountered, the contrast medium should be injected instead of forc-ing the catheter to pass through, and if no contrast medium exosmosis was found, the above procedure can be continued until the catheter passed through the spasmodic segment. If the extravasation of the contrast medium was found, elastic bandage should be applied immediately, and the contralateral radial ar-tery or femoral arar-tery should be selected for the puncture.

2.5. Statistical Analysis

[image:5.595.210.538.73.395.2]
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DOI: 10.4236/wjcd.2018.82017 174 World Journal of Cardiovascular Diseases

(a) (b)

(c) (d)

[image:6.595.208.539.59.592.2]

(e)

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DOI: 10.4236/wjcd.2018.82017 175 World Journal of Cardiovascular Diseases

(a) (b)

[image:7.595.210.537.71.404.2]

(c) (d)

Figure 3. Male, 66 years old, spasm in the radial artery and brachial artery together with severe dissection. (a): Spasm in the radial artery and brachial artery together with severe dissection, almost occlusive (between the single arrow and double arrow). (b): The BMW wire was damaged when attempting to pass through the spasmodic segment, while the Runthrough guiding wire successfully passed through (double arrow); the half of the bal-loon was placed in the guiding catheter and the rest was kept in the blood vessel, and ex-panded using 8 atm (single arrow). (c): BGCA passed through the dissected segment suc-cessfully (single arrow). (d): After PCI, spasm in the brachial artery and radial artery al-most disappeared, and the dissection was closed, no contrast medium exudation can be observed; local vascular stenosis and tortuosity can be observed (double arrow); the BGCA could pass through the tortuous and stenosis segment even if relatively large resis-tance was encountered.

variables were expressed as frequencies (n (%)) analyzed using Chi-square test; continuous variables were presented as means ± Standard Deviations (SDs) and analyzed using the two-tailed Student’s t-test. A p value of < 0.05 was considered statistically significant.

3. Results

3.1. Baseline Characteristics between the Two Groups

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[image:8.595.208.538.89.245.2]

DOI: 10.4236/wjcd.2018.82017 176 World Journal of Cardiovascular Diseases Table 1. Baseline clinical characteristics.

Characteristic Group A N = 168 Group B N = 73 p value

Male sex, n (%) 88 (52.4) 37 (50.7) 0.809

Mean age (years ± SD) 59.1 ± 13.3 60.7 ± 15.2 0.741 Hypertension, n (%) 124 (73.8) 54 (74.0) 0.979 Diabetes mellitus, n (%) 99 (58.9) 42 (57.5) 0.840

Alcohol, n (%) 38 (22.6) 20 (27.4) 0.762

Current smoker, n (%) 76 (45.2) 34 (46.5) 0.848 Unstable angina pectoris, n (%) 146 (86.9) 67 (91.8) 0.278 Acute myocardial infarction, n (%) 22 (13.1) 6 (8.2) 0.277

3.2. Comparison of Spasmodic Sites, Complication, Success Rate

and Time Consumption for Guiding Catheter Crossover

between the Two Groups

There was no significant difference in the spasmodic segment between the two groups (all P > 0.05), but the incidence of brachial artery spasm was higher than that of radial artery in the two groups. 1) All the PCI guiding wires used in group A successfully passed through the spasmodic or (and) the dissected seg-ment of blood vessel, and all guiding catheters passed through successfully. Ex-cept for five cases in which two guiding wires were applied (if a BMW wire failed to cross, then a Runthrough wire was applied, vice versa), the rest 163 cases were applied only one guiding wire, among which the BMW guiding wire was used in 102 cases and the Runthrough guiding wire was used in 61 cases. Significant re-sistance was encountered in one of the five cases using two guiding wires when trying to pass through the dissected site with a BMW guiding wire. It was almost trapped in the dissection sites when pushing forward and withdrawing the guid-ing wire. The tip of wire was found tightly knotted when removed from the body, so one Runthrough guiding wire was chosen and then passed through the spasmodic and dissected segment relatively smoothly; The reason why the other four cases using two wires also was that the wire tip was found damaged and de-formed and failed to pass through the spasmodic and dissected segment, then changed for another different wire and passed through eventually. 2) Only 28 cases in group B exhibited successful crossover of the spasmodic blood vessel which took a long time. That the patient with the longest time to cross over the spasmodic site was due to weak pulse in the contralateral radial artery and the patient’s resolute refusal of puncturing the femoral artery. It took nearly 40 mi-nutes for the catheter crossing over the spasmodic segment.

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DOI: 10.4236/wjcd.2018.82017 177 World Journal of Cardiovascular Diseases vascular dissection. For those patients, no elastic bandage was immediately needed if the guiding catheter could cross over the dissected segments within several minutes. If there was serious exudation and guiding catheter could not cross over the dissected segments rapidly, then the elastic bandage should be ap-plied. Four patients were the case in group A. After PCI was completed, angio-graphy was needed for all cases in order to observe if contrast medium exuda-tion still existed in the previously dissected segments. It was demonstrated that contrast medium exudation disappeared completely or nearly disappeared and no contrast medium exuded any more in all cases in group A. In group B, 14 (19.2%) patients exhibited postoperative hematoma, so the complication was tremendously lesser in group A than group B (4.2% vs 19.2%, p < 0.0001). The hospital stay was shorter in group A than group B (7.2 ± 5.7 vs 8.8 ± 4.9, p = 0.016). Generally, for patients with postoperative hematoma, the hospital stay would prolong for 2 to 4 days.

The time consumption of guiding catheter crossing over spasmodic segment was much shorter in patients of group A than that of group B (p < 0.0001). The majority of cases were less than five minutes in group A, on the contrary, most of cases were more than five minutes in group B (Table 2).

[image:9.595.209.538.481.728.2]

A 7F guiding catheter was chosen in five patients in group A and two patients in group B, respectively, and one 2.5 mm-in-diameter balloon was then selected so as to better match the diameter of the guiding catheter. In some cases, the an-giography could be completed by a 5F catheter successfully without being aware of the existence of radial or (and) brachial artery spasm. If PCI needed, a 6F guiding catheter and a 2.5 mm-in-diameter predilation balloon may be chosen.

Table 2. Spasmodic sites, complication, success rate and time consumption for guiding catheter crossover the spasmodic segment of the two approaches.

Parameter Group A N = 168 Group B N = 73 p value

Spasmodic sites

Radial artery 58 (34.5) 26 (35.6) 0.872

Brachial artery 92 (54.8) 36 (49.3) 0.436 Radial and brachial artery 18 (10.7) 11 (15.1) 0.340 Hematoma in forearm 7 (4.2) 14 (19.2) <0.0001 Guiding catheter crossover (yes or no)

Yes 168 (100.0) 28 (38.4) <0.0001

No 0 (0) 45 (61.6) <0.0001

Time consumption for Guiding

catheter crossover N = 168 N = 28 <0.0001

<5 min 157 (93.5) 4 (14.3)

5 - 15 min 11 (6.5) 19 (67.9)

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DOI: 10.4236/wjcd.2018.82017 178 World Journal of Cardiovascular Diseases Under the circumstances, it was hard for a 6F guiding catheter to pass through the spasmodic segment, nevertheless, it was not necessary to change another 2.0 mm-in-diameter balloon. On the basis of our experience, one 6F guiding cathe-ter and one 2.5 mm-in-diamecathe-ter balloon can also have a good match. Twelve cases in this investigation were the case.

4. Discussion

Trans-radial artery PCI has many advantages, so it has become the preferred approach for the interventional therapeutics of the majority of coronary heart diseases nowadays. However, the radial artery itself has some different characte-ristics, namely, its diameter is smaller than that of the femoral artery and prone to spasm; although the size of brachial artery is larger than that of the radial ar-tery, it also has the feature of being easily spasmodic [3], so it has become a common problem in trans-radial artery PCI.

The vessel wall of radial artery mainly consists of the α1-adrenergic receptor and a small amount of β receptor, which is extremely sensitive to the catechola-mine in the circulation [4] [5]. Vessel puncture, sheath intubation, and cathete-rization can directly stimulate the vessels, thus exciting the sympathetic nerve system, increasing the catecholamine level in the blood, and causing the radial artery spasm. Patients in PCI will be nervous and anxious, and feel pain, so it will increase the catecholamine level in the circulation, which may also cause the radial artery spasm. The direct stimuli of operation itself, as well as the intra-operative and postintra-operative activation via neural fluid mechanism (including the increase of endothelin or catecholamine, etc.) are also related to the radial artery spasm [6]. The reasons of the brachial artery spasm are similar to those of the radial artery. In addition, according to the data of this study, it seems that the brachial artery is more prone to spasm, which may be related to its more sensi-tivity to the catecholamine and endothelin, but the affirmative reason is still subjected to further investigation.

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DOI: 10.4236/wjcd.2018.82017 179 World Journal of Cardiovascular Diseases the 5F catheter can also pass through the spasmodic segment without being aware of its existence in most cases, at which time no angiography is generally performed for the confirmation, so that the incidence of the radial or (and) brachial artery spasm during PCI will be underestimated.

Once it is suspected that radial or brachial artery spasm occurs, angiography must be performed for confirmation. Actually, some suspected spasms are not the case. Under certain circumstances, the guiding wire and catheter do not fol-low the main stem of the radial or brachial artery, which may be inserted into a small artery of the elbow artery network (mostly into the radial recurrent artery or radial collateral artery). Because such vessels are smaller in diameter, a 5F ca-theter sometimes can pass through, and almost all 6 F caca-theters cannot pass through the spasmodic or (and) dissected segment although most 0.035"-in- diameter guiding wire can easily cross over those relatively small arteries. Once the catheter is pushed into small artery following the guiding wire, resistance can be perceived, then angiography should performed immediately for confirmation. If it is confirmed that catheter is in the radial recurrent artery or radial collateral artery or other small arteries, the guiding wire and catheter should be re-adjusted so as to make them in the main vessel.

When radial or (and) brachial artery spasm occurs in PCI, the most critical step for guiding catheter crossing over the spasmodic segment is to maneuver the PCI wire carefully to pass through the spasmodic segment. Often in clinical practice, when the operator feels resistance while pushing guiding catheter and is aware of the existence of spasm, vessel dissection (sometimes serious dissection) probably has occurred. At this moment, operator should stop the operation im-mediately and withdraw the catheter a little and inject contrast medium through the guiding catheter. Often after angiography, contrast medium extravasation can be found, sometimes even the real vessel lumen cannot be identified.

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DOI: 10.4236/wjcd.2018.82017 180 World Journal of Cardiovascular Diseases further confirmed by angiography. It may further aggravate dissection if the guiding wire was manipulated with violence, or even completely occlude the blood vessels. If the occlusion occurs in the brachial artery, it may cause acute upper limb ischemia. No such case occurred in this study, and the time con-sumption of spasmodic or (and) dissected segment crossover was within 5 mi-nutes in most cases.

After the guiding wire successfully passes through the spasmodic or (and) dis-sected segment, the predilated balloon can then be advanced through the guiding wire. Generally, a 6F guiding catheter corresponds to a 2.0 mm-in-diameter bal-loon, and a 7F guiding catheter corresponds to a 2.5 mm-in-diameter balloon. Sometimes, a 6F guiding catheter can also match a 2.5 mm-in-diameter balloon, the inflation pressure of balloon should be kept at 6 - 8 atm; thus the inflation pressure for a 6 F catheter and 2.0-mm balloon should be kept at 8 - 10 atm. Af-ter the balloon is dilated, half of it should be kept in the guiding catheAf-ter while the rest half should be kept in the blood vessel. Because the diameter of the bal-loon tip is less than its body, the extracorporeal pushing of the guiding catheter may result in the so-called “plow”-like movement of the balloon tip, and the body part will have the expansion effect toward the spasmodic segment of the vessel. After dilation, the balloon body and the guiding catheter will be in closely contact as a whole, therefore the guiding catheter can easily pass through the radial or(and) brachial artery spasm or(and) dissection by the aid of the balloon. Because the balloon surface is very smooth, it will cause no obvious damage to the vascular intima. It has been proved in clinical practice that the guiding ca-theter can pass through the spasmodic or (and) dissected segment almost with-out any resistance in most cases.

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DOI: 10.4236/wjcd.2018.82017 181 World Journal of Cardiovascular Diseases The application of PCI guiding wire and balloon assistance will not increase patients’ financial burden because it is also the operational instrument necessary in PCI, so no additional instrument is required. On the contrary, because no other blood vessel needs to be punctured, it also needs not another sheath, and more importantly, it will reduce patients’ suffering.

The combination with nitroglycerine and sodium nitroprusside has better ef-fect than nitroglycerin alone in relieving the radial or (and) brachial artery [1]; if the combined effect is still not obvious, diltiazem can also be combined. Howev-er, it is obvious that the administration of drugs to relieve spasm often takes longer time, and there are still a large number of patients that spasm cannot be relieved effectively.

Since the beginning of 2014, small-scale clinical observation concerning this approach had been carried out and analysed by the first author, revealing the success rate as 100%. Since then, this approach has been popularized and adopted by a number of interventionists in many domestic hospitals, and the success rates by different operators can also reach nearly 100%.

It was an observational rather than a randomized controlled trial, the sample size was still not too large. Because the investigation was mainly focused on the immediate effect and safety of a relatively new approach, the long-term effect on clinical treatment outcomes was not evaluated. On the other hand, some other important index, for instance, the hospitalization cost, etc. were not compared because of much difference among hospitals across the country in hospital charge system, case selection bias between the two groups (patients enrolled in group B had a greater proportion of earlier hospitalization time). Further inves-tigation in a larger patient population and in more operators is needed to cor-roborate the conclusions.

In short, the assistance of PCI wire and balloon is an extremely effective and safe approach for guiding catheter crossing over spasmodic or (and) dissected radial or(and) brachial artery in patients who PCI was undergone via radial ar-tery access, which is more effective and safer than that of conventionally admi-nistrating anti-spasmodic drugs. So the approach of PCI wire and balloon assis-tance is worth being strongly recommended.

Conflicts of Interest

The authors have no conflicts of interest to declare.

References

[1] Gwon, H.C., Doh, J.H., Choi, J.H., Lee, S.H., Hong, K.P. and Park, J.E. (2006) A 5Fr Catheter Approach Reduces Patient Discomfort during Trans-Radial Coronary In-tervention Compared with a 6Fr Approach: A Prospective Randomized Study. Journal of Interventional Cardiology, 19, 141-147.

https://doi.org/10.1111/j.1540-8183.2006.00121.x

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DOI: 10.4236/wjcd.2018.82017 182 World Journal of Cardiovascular Diseases Primary Angioplasty and Abciximab. Catheterization Cardiovascular Interventions, 61, 67-73. https://doi.org/10.1002/ccd.10675

[3] Lin, Y.J., Liu, Y.B., Chu, C.C. and Tsai, C.W. (2006) Predictors of Brachial Artery Spasm during Trans-Radial Cardiac Catheterization. Acta Cardiologica Sinica, 22, 134-141.

[4] Kiemeneij, F., Laarman, G.J. and de Melker, E. (1995) Trans-Radial Artery Coro-nary Angioplasty. American Heart Journal, 129, 1-7.

https://doi.org/10.1016/0002-8703(95)90034-9

[5] Wu, C.J., Lo, P.H., Chang, K.C., Fu, M., Lau, K.W. and Hung, J.S. (1997) Trans-Radial Coronary Angiography and Angioplasty in Chinese Patients. Catheterization Car-diovascular Interventions, 40, 159-163.

https://doi.org/10.1002/(SICI)1097-0304(199702)40:2<159::AID-CCD8>3.0.CO;2-A [6] Stella, P.R., Kiemeneij, F., Laarman, G.J., Odekerken, D., Slagboom, T. and van der

Wieken, R. (1997) Incidence and Outcome of Radial Artery Occlusion Following Trans-Radial artery Coronary Angioplasty. Catheterization Cardiovascular Inter-ventions, 40, 156-158.

https://doi.org/10.1002/(SICI)1097-0304(199702)40:2<156::AID-CCD7>3.0.CO;2-A [7] Dai, J., Yao, M., Qiao, S.B., Yang, Y.J., Qin, X.W., An, X.G., Hou, Y. and Liu, H.B.

(2004) An Analyzing the Causes of Procedural Failure and Complications of Coro-nary Angiography through Right Radial Approach. Chin Circ, 19, 175-177. [8] Chen, C.W., Lin, C.L., Lin, T.K. and Lin, C.D. (2006) A Simple and Effective

Regi-men for Prevention of Radial Artery Spasm during Coronary Catheterization. Car-diology, 105, 43-47. https://doi.org/10.1159/000089246

Figure

Figure 1. Male, 43 years old, radial artery spasm together with severe dissection. (a): row)
Figure 2. Female, 63 years old, brachial artery spasm together with severe dissection
Figure 3. Male, 66 years old, spasm in the radial artery and brachial artery together with severe dissection
Table 1. Baseline clinical characteristics.
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References

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